Health Care Privacy Forms
The following forms are used to submit requests mentioned in the Notices of Privacy Practices for Cigna HealthCare and Cigna Home Delivery Pharmacy.
To make a request, print and complete the appropriate form and mail it to the address indicated on the form.
If you want to receive Cigna correspondence at a confidential address, use this form:
- Request for Confidential Communications English | Español | Chinese
- Request for Confidential Communications for Oregon Residents English
- Request for Confidential Communications for Vermont Resident Crime Victims English
- Email or fax state specific forms to CHUSI@cigna.com, 877.815.4827 or 859.410.2419 or call the phone number on the back of your Cigna ID card and ask to speak with a Customer Service Associate
If you want to allow someone else (such as a spouse, friend or attorney) to access your health care information, use this form:
Authorization for Disclosure of Protected Health Information English | Español | Chinese
If you want to obtain a copy of your health care diagnosis and treatment code information that Cigna maintains, use this form:
Request for Diagnosis and Treatment Code Information English | Español | Chinese
Request for Diagnosis and Treatment Code Information Form (for Starbridge/Fundamental Care Limited Benefit Health Plans)